Dyslipidemia guidelines from the US and Europe take slightly different routes to similar ends. Test your knowledge of the twists and turns.
Drs Brownstein and Martin, both of the Johns Hopkins University School of Medicine, previously coauthored a comparative review of the ACC/AHA and ESC/EAS guidelines for Patient Care Online, which may be an ideal refresher after completing the quiz.
1. Which of the patients described above would be classified as “very high-risk” according to the ESC/EAS guidelines but not the AHA/ACC guidelines?
NSTEMI, non-ST-elevation myocardial infarction; PAD, peripheral arterial disease; T2DM, type 2 diabetes mellitus; HTN, hypertension; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; CAD, coronary artery disease; LAD, left anterior descending artery; LCX, left circumflex coronary artery; CTA, computed tomography angiogram
Answer: E. Both patients C and D would be defined as “very high risk” according to the ESC/EAS guidelines but not the AHA/ACC
The patients described in options A and B would be classified as very high-risk according to both sets of guidelines.
One of the central differences between the AHA/ACC and ESC/EAS guidelines is the definition of a “very-high-risk” patient, as shown above.
ASCVD, atherosclerotic cardiovascular disease; hFH, heterozygous familial hypercholesterolemia; CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; CHF, congestive heart failure
Neither patient above has experienced an ASCVD event, and so, the AHA/ACC guidelines would not classify either one as at "very high" risk.
2. A 54-y/o man w/ T2DM & HTN & recent NSTEMI presents to your clinic for follow up after his MI. His LDL-C at the time of his MI (on no statin Rx) was 130 mg/dL. His LDL-C today (2 mo post-MI) on atorvastatin 80 mg daily is 75 mg/dL. Which of the following next steps is recommended by the ESC/EAS but not the AHA/ACC guidelines?
Answer: D. Start ezetimibe for goal LDL-C reduction >50% and LDL-C level <55 mg/dL is the recommendation based on the ESC/EAS guidelines.
Both sets of guidelines qualify this patient as very high-risk. Another major difference between the 2 guidelines, however, is how to treat very high-risk patients.
Since atorvastatin 80 mg daily reduced this patient's LDL-C by <50%, ezetimibe is indicated to further reduce his LDL-C according to both sets of guidelines. The target for his LDL-C according to the ESC/EAS guidelines is <55 mg/dL and if ezetimibe does not decrease his LDL-C to that target, consideration should be given to starting a PCSK9 inhibitor.
3. Which of the above is an ASCVD risk enhancer according the AHA/ACC guidelines but not the ESC/EAS guidelines?
Answer: D. A history of preeclampsia is an ASCVD risk enhancer according to the AHA/ACC guidelines, but not the ESC/EAS guidelines.
Risk enhancers can be used by clinicians to help further stratify patients in primary prevention since there are numerous factors not incorporated into the ACC ASCVD risk estimator equation.
hsCRP, high-sensitivity C-reactive protein
The ESC/EAS guidelines include a variety of other risk enhancers to refine CV risk but do not include sex specific reproductive factors, including preeclampsia and gestational hypertension, which have been shown to modify ASCVD risk and are included in the AHA/ACC guidelines.
NAFLD, nonalcoholic fatty liver disease
4. A 48-y/o woman w/ a 12-y history of T2DM (A1c, 7.5%) on metformin presents to your clinic. She has no symptoms or evidence of end organ damage; her LDL-C is 130 mg/dL. Which of the next steps above is recommended by ESC/EAS guidelines but not the AHA/ACC guidelines?
Answer: B. The ESC/EAS guidelines for this patient recommend starting a statin for a goal LDL-C reduction ≥50% from baseline and LDL-C level <70 mg/dL.
The AHA/ACC guidelines recommend that in primary prevention, patients aged 40-75y with DM should be treated with moderate intensity statins unless they have multiple diabetes-specific risk factors, as noted above, in which case a high-intensity statin would be indicated.
According to the European guidelines, this patient would be classified as high risk given her DM has been present for >10y without end organ damage. Therefore, the target LDL-C for her is ≥50% reduction from baseline and LDL-C goal <70 mg/dL.
The AHA/ACC and ESC/EAS dyslipidemia guidelines share common ground and common goals.
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The 2018 American Heart Association/American College of Cardiology Multisociety Guideline on the Management of Blood Cholesterol (AHA/ACC) and the 2019 European Society of Cardiology/European Atherosclerosis Society Guidelines for the Management of Dyslipidaemias: Lipid Modificatnion to Reduce Cardiovascular Risk (ESC/EAS) share the common goal of reducing morbidity and mortality caused by cardiovascular disease. They differ, however, in definitions of risk, particularly in what constitutes a "high-risk" patient, and also in their goals for treatment.Follwing are 4 situations, including 3 hypothetical patients, that ask you to apply your knowledge of the differences between the European and US recommendations, followed by detailed rationale for the answers.